Cardiology Coding Alert

If you're still treating modifier 59 as a catchall, you could be attracting unwanted regulatory attention. Kick these three myths and maximize your modifier 59 (Distinct procedural service) use as well as your reimbursement.

Don't fall into the trap of using modifier 59 if another modifier (or no modifier at all) will tell the story more accurately. CPT guidelines clearly indicate "that the 59 modifier is only used if no more descriptive modifier is available and [its use] best explains the circumstances," according to the July 1999 CPT Assistant. You should use modifier 59 only as a last resort.

Bottom line: Append modifier 59 to a claim only if you are certain of the distinct nature of the procedures you are reporting, and never simply to override Correct Coding Initiative (CCI) bundles and get paid. "Modifier 59 is overused just to get through the edits," says Annette Grady, CPC, CPC-H, CPC-P, CCS-P, compliance auditor at The Coding Network and executive officer on the AAPC's National Advisory Board.

Coders often turn to modifier 59 because "it unbundles nicely," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, coding analyst with CodeRyte Inc. in Bethesda, Md.

Be smart: Each time you are unsure whether a carrier accepts modifier 59 or prefers some other modifier or reporting method, call the carrier immediately and ask for clarification, says Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Atlanta. Then, chart each carrier's policies on 59 so you know whether to use it the next time you file a claim.

Making these phone calls may take a little time initially, but once you get a chart with each insurance company's policy on modifier 59, your claims department will be streamlined dramatically.

Although you'll primarily use modifier 59 with codes that CPT designates as "separate procedure," you may still use it in other circumstances as well.

For instance, you may also use modifier 59 with the primary procedure if that procedure has the higher relative value unit (RVU). CPT states that this modifier is "appropriate under certain circumstances." They include:

1. A different session or patient encounter. This means the cardiologist provides a distinct service during a different patient encounter -- even though she may perform a similar procedure.

For example, your cardiologist performs a stress test (93015, Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; with physician supervision, with interpretation and report) on the same day as a diagnostic electrocardiogram (93000, Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report). You should apply modifier 59 to the ECG to show that these procedures are separate services, rather than a portion of the stress test.

2. A different procedure or surgery. Your doctor places a temporary pacemaker (33211, Insertion or replacement of temporary 'transvenous dual-chamber pacing electrodes' [separate procedure]) in the morning and later in the day implants a dual-chamber permanent pacemaker (33208, Insertion or replacement of permanent pacemaker with transvenous electrode[s]; atrial and ventricular). In this case, you'll need to attach modifier 59 to 33211 to illustrate that it was a separate procedure from the permanent pacemaker implantation. Otherwise, you'll face a denial.

3. A different anatomic site or organ system. For example, your cardiologist performs a catheterization of the right vertebral (third order) and left vertebral (second order) from femoral access. You should use 36217 (Selective catheter placement, arterial system; initial third-order or more selective thoracic or brachiocephalic branch, within a vascular family) for the right vertebral and 36216 (... initial second-order thoracic or brachiocephalic branch, within a vascular family) for the left vertebral.